PATIENT PROFILE: Ms. N is a 68-year-old African Caucasian woman. She lives in Chattanooga.

She decided to come to the dental hygiene clinic for her cleaning, she was overdue due to
moving out of state.
MEDICAL HISTORY SUMMARY: Ms. N reports having no systemic diseases. Patient was asked
about surgeries and any other medical conditions; patient denied any significant medical
history has happened.
The patient takes no prescribed medications at the current time. She does not take a daily
multivitamin. The patient does not take aspirin, because it upsets her stomach.
VITALS AT VISIT #1
BP: 122/78 mm Hg steady
PR: 68 bpm steady
RR: 14 rpm steady and deep
O2: 96%
TEMP: 97.8 F
ASA CLASSIFICATION: ASA I

VITALS AT VISIT #2
BP: 124/76 mm Hg
PR: 78 bpm steady, strong
RR: 16 rpm steady
O2: 96%
TEMP: 98.0 F
ASA CLASSIFICATION: ASA I
SUMMARY OF HEALTH
Patient is a 68-year-old Caucasian woman in good health. No medications nor conditions to
note.
PAST DENTAL HISTORY: The patient was seen by a private dentist about 1 year ago to have her
teeth cleaned. She has not been to a dentist since. Patient had #24 extracted in 2018 due to a
failed root canal. Had Invisalign after to close space.
CHIEF COMPLAINT: Ms. N came to the dental hygiene clinic because she is “overdue for a
cleaning”
CLINICAL FINDINGS:
Extraoral examination: The patient presents with facial symmetry. No palpable lymph nodes,
parotid glans is within normal limits, two macules along right hairline, light brown in color with
regular borders, 3X2mm in diameter, scab on left side of lower lip.

Radiographic findings: generalized composite restorations throughout the mouth. Wisdom

teeth have been extracted. #24 extracted in 2018 due to a failed root canal. Root canal on #9.
Localized horizontal bone loss present.

Intraoral examination: bilateral linea alba, scalloped tongue, bite mark on left buccal mucosa
(1mmX1mm), bilateral mandibular tori
Class II division I
Overbite: moderate
Overjet: 6mm
Caries Risk Assessment: Moderate. Patient does not have an established dental home, has
exposed root surfaces, and has a fixed dental appliance (bridge) on teeth #6-#11.

Gingival Assessment: The gingiva is pale pink throughout with red margins along maxillary
bridge. Conforms to tooth but slightly enlarged papilla along maxillary bridge. Gingival margin is
below the cementoenamel junction on areas where recession is present. Knife-edged, slightly
blunted between #23 & #25. Papilla fills contact. Tissue is firm, slightly spongy along mandibular
and maxillary anterior teeth. There is stippling present throughout. Generalized 1-3mm pockets
with localized 4-5mm pockets with slight bleeding.

Periodontal examination: The patient presented with a periodontal maintenance on a reduced

periodontium. Most severe in the mandibular lower left quadrant. Calculus was generalized
throughout the mouth with the heaviest deposits located on the lower anterior teeth. Patient
presents as a calculus skill class II and periodontal skill class II.

Maxillary Probe Readings

DENTAL HYGIENE DIAGNOSIS:

Loss of attachment present in quadrant 2 and 3. Radiographic loss of interdental bone is
apparent. The patient presents with Stage 2 Grade A periodontitis.

DENTAL-HEALTH EDUCATION:
Plaque Control Record: 17%, would like to see below 10% at next visit
The patient brushes her teeth twice a day but does not floss. The CHARTERS technique was
recommended twice daily for areas with recession along with interdental flossing. Instructed
the patient to conform the floss in a C shape below the gingival margin to remove biofilm.
Incorporate flossing 3x per week and increase to at least 5x per week at next visit.
Recommended Sonicare toothbrush with sensitive head for recession. Brush 2x per day for at
least 2 minutes.

PLANNING:
Rationale for case selection:
Because of the nature of the calculus deposits, the depth of the
periodontal pockets, and the patient's willingness to improve her oral conditions, this
patient will benefit by participating in a periodontal maintenance on a reduced periodontium.
No anesthesia was needed. With proper home care instruction and periodontal maintenances,
the patient's tissue should respond well.

Goals:
1. Improve the health status of the gingiva, teeth, and supporting ligaments.

2. Remove all hard deposits so that the patient can effectively clean her own mouth, especially
around areas where restorations are present.
3. Have the patient adopt an oral hygiene regimen to effectively disrupt and remove plaque.
4. Reduce the depth of periodontal pockets.
5. Encourage the patient to remain on a preventative regimen of routine re-care.
Initial treatment plan:
Appointment 1:
Medical and dental history; intraoral, extraoral examination
4 bitewing x-rays, 1 PA and panoramic image taken at initial visit (full mouth series sent over
from previous office); initial series of intraoral photographs
Complete gingival assessment and periodontal evaluation
Calculus detection
Treatment plan proposal
Comprehensive exam completed at initial visit
Appointment 2:
Dental health education: emphasis on brushing technique and flossing. Plaque score.
Complete debridement of quadrants 1-4 with Piezo and hand scale, polish with fine grit bubble
gum paste, floss. Patient denied fluoride.
Appointment 4:
Re-care visits at 4-month intervals
IMPLEMENTATION: The treatment proceeded as planned. The patient was receptive to
all procedures. No skill roadblocks were encountered with dental health education. The patient
was able to demonstrate adequate skills with a charters toothbrushing technique and c-shape
flossing technique. The plaque index will be recorded at next visit to see if there has been any
improvement.
Hygiene procedures were accomplished with a minimum of difficulty.
Treatment revisions:
Appointment 3:
At this visit, we will re-evaluate how she responded to treatment. Patient is on a 4 month re-
care and will be due for her next appointment at the end of September.
Follow-up periodontal charting will be assessed and discussion over re-call appointments will be
addressed based off findings.

EVALUATION: Ms. N was treated in the dental hygiene clinic for a period of 2 days. No
reevaluation appointment was necessary for this patient due to her being a periodontal
maintenance on a reduced periodontium.
At next appointment, patient should be able to demonstrate an adequate technique for
brushing and flossing. Plaque score was a 17% at initial visit, we would like to see it below 10%
at her next visit to the clinic. The patient should be able to effectively remove plaque and value
her newly acquired skills and the appearance of her tissue. Continued home care will be
reinforced and changes to homecare will be addressed at next visit.
RESULTS: Final results will be addressed at 4-month periodontal maintenance. At this visit, it
will be decided what re-care she should be placed on. If not improvement, 3-month re-care. If
patient shows great improvement, we will keep at 4-month re-care and re-evaluate at next
appointment.
The patient is pleased that the goals for this phase of treatment were accomplished.
Ms. N will be seen for periodontal recall in 4 months.